Some improvised surgical operations performed in remote areas of East Africa
“The better part of valor is discretion.”
-William Shakespeare (King Henry IV)
“The graveyards are full of the indispensables.”
-Charles de Gaulle
One early morning, our clinical officer sent an orderly to my house asking me to come over urgently to the hospital “Casualty” a term later replaced with “Emergency.”
A young Swahili lady had presented with a painful rigid abdomen, low back pain, and pain at the tip of both shoulders. She was cold, pale and sweaty, and had a rapid thready pulse. Her blood pressure chart showed it going progressively low. She was losing blood in her abdomen which was irritating the cavity’s lining. The clinical officer was thorough in his inquiry into the history of her illness; the patient had missed her “period” a couple of months earlier. When I asked for the “operation theater” to be informed to be put on the ready, .the smart clinical officer said he had already looked into that.
The prospect of “opening her up” to look inside her abdomen to verify the cause and “do the needful,” had rendered me a wee bit cold, pale and sweaty. After all, I had only had the most basic of surgical training and minimal experience. “Keep up your chin and get on with it,” I said to myself. “Pray for His guidance and hope for the best.”
This was a case of “ectopic” tubal pregnancy where the fetus develops outside of the uterus (womb) in one of the two “fallopian tubes,” which normally carry the egg to the womb. The tubes are not meant for embedding the growing embryo (fetus). If this happens, it grows in bulk and ruptures the tube with the resultant bleeding. Not operating on the patient to stem the bleeding leads to shock and almost certain death.
The surgical procedure comprised of clamping and removing the ectopic lump, filtering and re-infusing the blood which had collected in her abdominal cavity and closure of the initial surgical cut I had made in the abdominal wall to look inside.
The feeling of having successfully handled such situations this under trying circumstances is indescribable. It is teamwork but as head of the team, one feels euphoric, even indispensable, knowing fully well, “the graveyards are full of the indispensables.”
Routine Surgeries and Procedures
We did some routine repairs of inguinal hernias. I was becoming progressively more confident and daring. It may be that I was becoming addicted to the release of endorphins in my body and was enjoying the resultant euphoria. Self-confidence and job satisfaction were at their peak.
A middle-age lady presented with a painful firm swelling inside her pelvis. She came to consult us with her complaints of heavy, painful periods, pain in the lower back, abdomen, pelvis. She had chronic constipation, and increased frequency and difficulty in passing urine. These complaints had grown progressively and were worse during her periods.
Her story, coupled with my gynecological examination, made me presume it to be a “fibroid” of the uterus. She was overly keen that something be done to rid her of this dreadful problem. It turned out to be a relatively straightforward surgical operation, wherein the swelling the size of a tennis ball was snipped at its attachment to the wall of the uterus. However, what was strange was that the swelling, as well as the uterus with its tubes and the ovaries, were riddled with bluish green patches. I closed the abdomen after taking a biopsy, went to my office, opened my textbook and found this to be a relatively rare case of ‘endometriosis.’
This simply means there was presence of bits of the inner lining of the uterus (which normally bleeds during monthly periods) onto the outer surface of the uterus, the adjoining tubes and ovaries. It follows that all these patches bleed just like the uterus does during menstruation and give the typical menstrual symptoms of pain and spasm. A biopsy, i.e., a small snip of this tissue, was sent to the laboratory at the main hospital in Mombasa for microscopic examination. Meanwhile, she was put on hormone therapy with a view to stopping the monthly cycle of menstrual periods. She responded reasonably well to this therapy.
First, Do No Harm
A month later, an elderly fisherman with weather beaten, wrinkled facial features was brought to hospital on a homemade pram, carried by means of poles on the shoulders of his four sons. He was suffering from “urinary retention” i.e., the inability to pass urine and a fully distended urinary bladder. We lost no time in performing the first part of the operation, namely, relieving his distressful urinary obstruction by draining the urine. We did this by inserting a “cystostomy” catheter tube directly into the bladder through a “stab” in the skin and underlying tissues in the midline just above the pubes.
The cause was an enlargement of the prostate gland compressing the urinary outlet at the bladder. After a period of hydrating the patient with fluids, guarding against urinary infection and ensuring maintenance of kidney function, a major operation to remove the enlargeed portion of the prostate gland is normally performed a few days later by specialist surgeons in specialized hospital units. The prospect of me operating on him was mouthwatering.
I had planned on the age-old method, prevalent at the time, of literally “fingering out” the enlarged portion of the gland blindly and attempting to stop the resultant bleeding by tightly packing the raw area created with cotton swabs. But better judgment prevailed. The seriousness of complications of excessive bleeding, and the associated complication of failure of kidneys, combined with the lack of back-up facilities in my hospital and the deficiency in my experience, could all amount to an untoward, even a disastrous outcome.
“First, do no harm!” says the Hippocratic oath. Better safe than sorry. Look before you leap. I removed him from the operation list, even though he and his retinue - the entire extended family, were looking upon me as if I possessed the healing powers of Jesus Christ.
We made arrangements for him to be transferred to the main provincial hospital in Mombasa where I previously worked. The ‘ambulance’ was the same hard-suspensioned bumpy Land Rover that had first brought me to Lamu, He bore a referral letter to my senior colleague, Dr. Cunningham.
In all fairness, a remote island like Lamu, literally cut off from the rest of the country, deserved much better medical and surgical facilities and experienced specialists in various medical fields. But understandably, the exigencies of services and circumstances at that point in time did not permit this. Presently however, I have determined better facilities do exist alongside considerable upgrading of the hospital.
Mother and Grandmother
My maternal grandmother had always looked upon me as a tall, dark, and handsome guy. She suffered from a mortal fear of flying in aircrafts, as well as sailing in boats - motorized or otherwise. I was her favorite grandson, which was no mean feat as she was an independent minded person, known for not picking her favorites easily. As a matter of fact, she liked me more than some of her own children, and this state of affairs suited them well, because it apparently relieved them from attending to her many personal chores and demands. As a result, mos of these duties fell upon me to fulfill.
She had adopted me not merely as her favorite grandson but ever since I had returned after qualifying, as her favorite doctor. She solicited treatment from me for various ailments including, soon after she visited me in Lamu, an injection of a corticosteroid into her worn out arthritic knee joint. Luckily, she experienced considerable relief.
Both she and my mother bore a firm belief that I was blessed with healing powers. “He is blessed with the Healer’s hand,” an obvious reference to Jesus Christ. My mother was thoroughly impressed when, within the first few days of my arrival, she got dramatic relief and got cured with some tetracycline antibiotic capsules I gave for her throbbing, infection around her thumbnail. What a paradoxical relief when, just a day earlier, a close doctor friend had jokingly told me he wouldn’t so much as trust me with his ingrown toenail!
In view of my fair complexion, Grandma, or “nani-jee” in my mother tongue, had in my childhood nicknamed me “Mzungu,” a Swahili word meaning European. She would in fact, almost always greet me by saying “Hi, Mzungu.”
She had superseded my parents by taking upon herself the role of sheltering and protecting me from the “evil eye of the jealous.” She often chanted relevant verses from the Holy Koran, entreating God, while holding her breath, then blowing out her breath uniformly over my body. She did this to remind me, at all times, to beware of the beguiling and bewitching magic spells of the bewilderingly beautiful local Swahili women of the Lamu archipelago and the immigrant mix of “those pretty and provocative” Baluchi women, members of the families of migrants from the province of Baluchistan in the Indo Pak subcontinent.
I was admittedly one of the most eligible bachelors of the time in this insulated cocoon of an island and have no hesitation to state, at the risk of being immodest, that I could perceive the hot demand for me amongst the eligible ladies and, of necessity, their parents. This would be in line with the local conservative Muslim culture which advocates arranged marriages under the patronage of parents.